Relative efficacy and safety of early lactate clearance-guided therapy resuscitation in patients with sepsis: A meta-analysis

Jianzhen Pan, Milin Peng, Chao Liao, Xia Hu, Aimin Wang, Xiangmin Li, Jianzhen Pan, Milin Peng, Chao Liao, Xia Hu, Aimin Wang, Xiangmin Li

Abstract

Objective: Compelling evidence has shown that aggressive resuscitation bundles are one of the cornerstones of the successful treatment of patients with sepsis. Recent studies suggest that lactate normalization during resuscitation is a more powerful indicator of resuscitative adequacy; however, early lactate clearance-guided therapy is still not recommended. We performed this meta-analysis to evaluate the effect of early lactate clearance-directed therapy as a potentially more effective resuscitation target.

Methods: Studies were identified using PubMed, Embase, and the Cochrane Library without region, publication type, or language restrictions. Randomized trials were included when they compared the efficacy and safety of lactate clearance-guided resuscitation versus central venous oxygen saturation (ScvO2)-guided therapy. The primary outcome was mortality, and the secondary outcomes were intensive care unit (ICU) stay, length of hospital stay, mechanical ventilation time, Acute Physiology and Chronic Health Evaluation-II (APACHE-II) score, and Sepsis-related Organ Failure Assessment (SOFA) score.

Results: Seven randomized controlled trials encompassing 1301 cases were reviewed. Compared with guided ScvO2 therapy, early lactate clearance-directed therapy was associated with decreased in-hospital mortality (relative ratio [RR] 0.68, 95% confidence interval [CI] 0.56 to 0.82), shorter ICU stay (mean difference [MD] -1.64 days, 95% CI -3.23 to -0.05), shorter mechanical ventilation time (MD -10.22 hours, 95% CI -15.94 to -4.5), and lower APACHE-II scores (MD -4.47, 95% CI -7.25 to -1.69). However, patients undergoing early lactate clearance-guided therapy had similar lengths of hospital stay and similar SOFA scores.

Conclusions: As a specific indicator of resuscitation outcome, lactate clearance alone is superior to ScvO2 alone during a standard resuscitation paradigm. The optimal or desired rate of lactate clearance is still a contentious area. To guide resuscitation and normalize lactate levels in patients, repeating lactate measurements every 2 hours until the patient has met a lactate clearance of 10% or greater may be helpful.

Trial registration number: PROSPERO CRD42018100515.

Conflict of interest statement

The authors report no conflicts of interests.

Figures

Figure 1
Figure 1
Flow diagram of study inclusion. RCT = randomized controlled trial.
Figure 2
Figure 2
Effect of lactate clearance-guided therapy on in-hospital mortality compared with ScvO2-guided therapy. CI = confidence interval, M-H = Mantel-Haenszel.
Figure 3
Figure 3
Effect of lactate clearance-guided therapy on hospital length of stay (A) and intensive care unit length of stay (B) compared with early goal-directed therapy. CI = confidence interval, SD = standard deviation.
Figure 4
Figure 4
Effect of lactate clearance-guided therapy on mechanical ventilation (A), Sepsis-related Organ Failure Assessment score (B), Acute Physiology and Chronic Health Evaluation-II (C) compared with early goal-directed therapy. CI = confidence interval, SD = standard deviation.
Figure 5
Figure 5
Publication bias of in-hospital mortality. RR = relative ratio
Figure 6
Figure 6
Trial sequential analysis. ScvO2 = central venous oxygen saturation, TSA = trial sequential analysis

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Source: PubMed

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